State ________, Incorporated place ________. Ward of city _________; Unincorporated place
[Name of unincorporated place having 100 or more inhabitants] _______________________.
County _______________. Township or other division of county ________________________.
Block Nos. ___________; Institution [Name of institution and lines on which entries are made] _________________________________.

Household Data:
3. Number of household in order of visitation.
4. Home owned (O) or rented (R).
5. Value of home, if owned, or monthly rental, if rented.
6. Does this household live on a farm?
(Yes or No).
7. Name of each person whose usual place of residence on April 1, 1940, was in this household. Be sure to include:

1. Persons temporarily absent from house-hold. Write "Ab" after names of such persons.
2. Children under 1 year of age. Write "Infant" if child has not been given a first name. Enter X after name of person furnishing information.

8. Relationship of this person to the head of the household, as wife, daughter, father, mother-in-law, grandson, lodger, lodgers wife, servant, hired hand, etc..

Education:
13. Attended school or college any time since March 1, 1940.
14. Highest grade of school completed.

Place of Birth:
15. If born in the United States, give State, Territory, or possession. If foreign born, give country in which birthplace was situated on January 1, 1937. Distinguish Canada-French from Canada-English and Irish Free State (Eire) from Northern Ireland.
16. Citizenship of the foreign born.

Residence, April 1, 1935:
In what place did this person live on April 1, 1935? For a person who, on April 1, 1935, was living in the same house as at present, enter in Col. 17 "Same house," and for one living in a different house but in the same city or town, enter "Same place," leaving Cols. 18, 19, and 20 blank, in both instances. For a person who lived in a different place, enter city or town, county, and State, as directed in the Instructions. (Enter actual place of residence, which may differ from mail address.)
17. City, town, or village having 2,500 or more inhabitants. Enter "R" for all other places.
18. County.
19. State (or Territory or foreign country).
20. On a farm? (Yes or No).

Persons 14 Years Old and Over -
Employment Status:

21.Was this person AT WORK for pay or profit in private or nonemergency Govt. work during week of March 24-30? (Yes or No).
22. If not, was he at work on, or assigned to, public EMERGENCY WORK (WPA, NYA, CCC, etc.) during week of March 24-30? (Yes or No).
If neither at work nor assigned to public emergency work. ("No" in Cols. 21 and 22).
23. Was this person SEEKING WORK?
(Yes or No).
24. If not seeking work, did he HAVE A JOB, business, etc.? (Yes or No).
25. Indicate whether engaged in home house-work (H), in school (S), unable to work (U), or other (Ot).
26. Number of hours worked during week of March 24-30, 1940.
If seeking work or assigned to public emergency work. ("Yes" in Col. 22 or 23).
27. Duration of unemployment up to March 30, 1940 - in weeks.

Occupation, Industry and Class of Worker:
For a person at work, assigned to public emergency work, or with a job ("Yes" in Col. 21, 22, or 24), enter present occupation, industry, and class of worker. For a person seeking work ("Yes" in Col. 23):
a) If he has previous work experience, enter last occupation, industry, and class of worker; or
b) If he does not have previous work experience, enter "New worker" in Col. 28, and leave Cols. 29 and 30 blank.
28. Occupation: Trade, profession, or particular kind of work, as frame spinner, salesman, rivet heater ,music teacher.
29. Industry: Industry or business, as cotton mill, retail grocery, farm, shipyard, public school.
30. Class of worker.
31. Number of weeks worked in 1939 (Equivalent full-time weeks).

Income in 1939
(12 months ended December 31, 1939):
32. Amount of money wages or salary received (including commissions).
33. Did this person receive income of $50 or more from sources other than money wages or salary (Yes or No).
34. Number of farm schedule.

Supplementary Questions 33-50 asked only of a 5% sample of the population, for persons 14 years old and over. (For persons enumerated on lines 14 and 29).
35. Name.

Place of Birth of Father and Mother:
If born in the United States, give State, Territory, or possession. If foreign born, give country in which birthplace was situated on January 1, 1937. Distinguish Canada-French from Canada-English and Irish Free State (Eire) from Northern Ireland.
36. Father.
37. Mother
38. Language spoken in home in earliest childhood.

Veterans:
Is this person a veteran of the United States military forces; or the wife, widow, or under-18-year-old child of a veteran?
39. If so, enter "Yes."
40. If child, is veteran-father dead? (Yes or No)
41. War or military service.

Social Security:
42. Does this person have a Federal Social Security Number? (Yes or No)
43. Were deductions for Federal Old-Age Insurance or Railroad Retirement made from this persons wages or salary in 1939? (Yes or No)
44. If so, were deductions made from (1) all, (2) one-half or more, (3) part, but less than half, of wages or salary?

Usual Occupation, Industry, and Class of Worker:
Enter that occupation which the person regards as his usual occupation and at which he is physically able to work. If the person is unable to determine this, enter that occupation at which he has worked longest during the past 10 years and at which he is physically able to work. Enter also usual industry and usual class of worker.
45. Usual occupation.
46. Usual industry.
47. Usual class of worker.

For all women who are or have been married:
48. Has this woman been married more than once? (Yes or No)
49. Age at first marriage.
50. Number of children ever born (do not include stillbirths).